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Curbside Consult with Dr. Jayne 5/14/18

May 14, 2018 Dr. Jayne No Comments


I had a chance to catch up last week with Jonathan Bush of Athenahealth while he was at the HLTH conference in Las Vegas. He had reached out a while back, after reading my Curbside Consult on burnout and the concept of “moral distress.” After some email tag with his team, we were able to get something on the books. The timing couldn’t have been better since he had been scheduled to present on the topic of physician burnout at the conference.

As a healthcare technology leader, Bush has a unique opportunity to try to address the fact that more than 70 percent of physicians feel disengaged. They’re pressured to deliver better outcomes while using new systems, sharing information, and trying to keep patients satisfied. I asked him what he thinks is the secret for solving this problem, and in true Jonathan Bush deadpan style, his response was, “Create a top-down mandate with a bunch of complicated metrics.”

Conversations with him are always fun, and in addition to being knowledgeable about many aspects of healthcare, he’s quick-witted and always has great analogies. In this case, he likened the inertia we face in healthcare to being “like a fused tectonic plate. All we seem to do is type new data all day and we have no new insights.” He’s encouraging healthcare leaders to consider what will happen if they don’t figure out how to re-engage physicians and bring back the joy in practicing medicine. He refers to the need to create “capability,” which constitutes the tools and resources physicians need to get the job done, as well as the organizational latitude to make decisions that can positively impact their situations.

He wants leaders to engage burnout just like they would engage any other agile project. We need to create a framework and gradually iterate, while over time watching the data to see whether we’re making a difference. We need to look at the resources and tools we are deploying, and how much latitude we are giving the front-line players, and keep tracking it.

Much of what he promotes aligns with the philosophy of having everyone work to the top of his or her license, where they are doing the work they are uniquely qualified to do rather than doing work that can be done by other members of the care team. He urges organizations to get rid of things that don’t matter, to replace portions of the doctor’s day that are inconsequential, and to help them focus on items that are consequential and where a physician’s judgment is necessary.

Although this seems straightforward, I continue to find organizations that simply don’t understand this and continue to mire physicians in day-to-day activities such as prescription refills, where a protocol and trained staff could get the job done with reproducible outcomes.

We chatted a bit about his days as an ambulance driver, where he would look at his run sheet at the end of the day and see how many of his trips truly mattered and how many were an “overpriced taxi service with a lot of paperwork attached.” He mentioned that, “Once in a while, there was a truly consequential run,” but that it was “anxiety-producing to have things that matter mixed in with things that don’t matter.”

I talked a bit about my time in the emergency department and now in urgent care, seeing similar situations and having some of it being amplified by the consumerism we are seeing in healthcare today. We talked about the good stress that can be “beautiful” when it’s productive and the bad stress that ensues “when it’s an ER shitshow.” For those of you who may think that term is crass, it’s the language of the trenches, and it accurately portrays what it feels like on a bad day.

That part of the conversation illustrates one of the reasons I am glad he is in healthcare and likes to poke the bear at times. Despite his family background, he’s had some real-world life experiences that resonate with us in the trenches. He knows how to bring the conversation to where you are, which is a big difference from other leaders I’ve talked to who tell stories that somewhat alienate the audience. Talking to Jonathan Bush, you want to believe in what he is selling, and I’m sure it resonates with his customers.

We talked a bit about telemedicine vs. emergency medicine and the potential of technology to help alleviate the “unfortunate misery cycle” that many providers find themselves in. We then moved on to the newest 1,800+ pages of proposed CMS rulemaking. His take on the regulatory environment is that, “Working on things that don’t matter leads to attrition, not just with physicians, but in healthcare IT as employee engagement goes down.” I agree, as I have seen some of the most brilliant IT people I’ve ever worked with move into non-healthcare jobs because they don’t feel like they’re making a difference despite working hard for good organizations. My two favorite architects have gone to work in the automotive industry and the packaging industry, with a significant decrease in stress and greater job satisfaction because they feel they can actually complete projects and deliver outcomes without a constantly shifting set of requirements and priorities.

Bush cites the various mandates as creating structures where it’s too hard to change the mold. He likens some of the challenges that organizations face to a nesting doll, where you keep peeling back the layers but find more of the same underneath. He noted that people don’t care about many of the PQRS quality measures and he’s not sure that the people who wrote them even care about them. I had to laugh at that, as I also did when he said that people “need to liposuction things like the Joint Commission out of their lives.” I told him about my practice’s experience opting out of Meaningful Use and MIPS and how we made the decision. He liked the fact that we were able to “break a rock off of that tectonic plate” and that our leadership felt the latitude to do what was effective and engaging for our practice.

We talked about interoperability and the need to not only connect to everyone who has data, but also to get rid of the “nonsensical” data. Having recently received a 22-page C-CDA that was almost undecipherable, I agree. Even with my EHR’s algorithm to try to de-duplicate the data, I still had a pile of data points to review with very little time on my hands. Bush has a vision of a data lake where EHR data flows and is normalized and rationalized, made relevant by the addition of AI, and fed back to you in ways that are relevant. Until then, though, “EHR is like a bad marriage. You do everything for it and it does nothing for you except ask for more money every year. How about telling me something about my patient that I didn’t type in myself?”

Hearing a vendor executive say things like that is refreshing. He wasn’t talking about how great his product was, or why it’s the best. He realizes that our current systems have flaws and wants the EHR to be a beautiful virtual assistant that finds out everything about your patient before they arrive and a cool tool that helps you be better. But to get to that point, we need more data science in medicine and need to address the governance around what needs to be reconciled and what can be left as is.

Although addressing physician burnout is essential to keeping physicians from becoming endangered, we closed by touching on the other benefits of dealing with burnout, namely the economic benefits. Happy physicians are productive physicians and happy physicians don’t have to be replaced, which in my community can result in a cost in excess of $250K for a primary care physician.

By that point, Bush was getting “the hook” from his team and had to run to his next engagement, but I appreciated his willingness to spend a little time with an anonymous physician. The conversation was engaging and inspired me to keep working to push things forward with the organizations I have the ability to touch. Those of us in healthcare IT need to build a better mousetrap, or at least work to break up those tectonic plates.

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